Friday, 22 August 2008

**bleep... **bleep... goes my pager and I find a phone and dial the in the number.

“Hello?” comes the reply

“Hello, it’s Michael here, Anaesthetics. Were you paging me?”

“Err.. yes, It’s Shri here, surgical SHO. I was wandering if you could help us? We have a woman who needs some I.V. fluids but I’ve tried to site a cannula into her but I can’t. I was wandering if you were free to come and do this venflon for us? One of your colleagues kindly came and did it for us earlier today.”

“An anaesthetist came and put a venflon into her earlier?”

“That’s right, the registrar came and did it earlier”

“And what happened to that venflon?”

“It came out”

“Well, that’s not very responsible of you is it? Why didn’t you secure the line properly and make sure it doesn’t come out?”

“I don’t know. It just came out.”

“And you’ve tried and can’t put it back again?”

“Well, we tried earlier but none of us can do it”

“Has your registrar tried?”

“No.”

“Well, I don’t think it’s appropriate for you to call me to put in venflons in your patients.”

“I’m sorry??” comes the shocked voice at the end of the line. “One of you colleagues…”

“What one of my colleagues did as a favour is neither here nor there." I interupt. I'm getting a tad irritated by requests like this. "Look, this is what you should do. If you can’t put a venflon in, you need to call your registrar to come and do it, if he can’t do it then he needs to call the consultant to do it. If the consultant doesn’t want to do it then he needs to either get your reg to put in a central line or discuss with the ICU consultant about putting in a central line on the CEPOD list. If the ICU consultant agrees to that then we’ll come and put in a central line.”

“But I don’t think she needs a central line…”

“Then I suggest you either put a venflon in yourself or get one of your surgical colleagues to put one in. You guys are doctors too aren’t you?”

“But…”

“I’m not coming to do it. End of story. Either you sort it out yourselves or you go through the ICU consultant. Putting in your venflons is not what I’m on call for. Goodbye.”

Unsurprisingly, I didn’t hear anything more about that venflon. To me, there is a big difference between "helping" and "doing someone else's job for them."

I've become a tad irritated by requests like this when I'm on call. It seems that the attitude in my new hospital is to call the anaesthetist if there's a vaguely challenging cannulation to do.

Simon F, if the lady in question was indeed hypovolaemic and in need of further support whilst being difficult to cannulate, then the surgical team should be thinking of definitive access anyway, as I suggested. I really don't think that was the case though - I think they were just taking the piss

Hey there Dr.Anderson. long time no speak. Well said in my opinion, venflon insertion is a basic procedure, which even me, a clinical student, knows how to do. Also anaesthetists shouldn't be wasted on these things, especially when they have a whole team backing them up.

Wow-I have to say I've unfortunately been the person on the other end before once or twice. The thing is (especially in Ireland, when "on call" means 36 hours straight awake with no break) your registrar is really grumpy and angry to hear from you about a cannula sometimes. If the intern has tried multiple times, you have tried multiple times, and the patient is just not cannulatable (and despite snide comments about it being a basic procedure, the reality at 3am in an ill patient with extremely poor veins and being shut down is different, as you will no doubt find out, ally, when you stop being a student) then your reg will often growl menacingly at you to sort it out, and tell you to call the anaesthetics person, as they are currently up the walls with 16 referrals down in ED. If you protest and say you shouldn't do that, you are in for a serious bollocking from your registrar, someone you should not alienate, as at 5am when you can't get the lumbar puncture on that obese lady, they are your only port of call-although they may refuse and leave you in the shit-as has happened before, and you will end up explaining to your consultant in the morning that a lumbar puncture has not been done, and they will be, um, less than impressed. I'm actually usually pretty awesome with cannulation, having done both oncology and geris, but there are times when it just ain't happening, unfortunately out of hours there are not enough staff on and there is just no-one else to ask. The thing is, okay, maybe you think they should have a central line or PICC, but quite often the hoops you have to jump through to get these are a bit insurmountable at 3am. This gives me an unpleasant flashback of what it was like back at home yet again, everyone angry at you and telling you off all the time-and it is miserable. Michael, don't be that guy! Explain nicely that you feel it isn't appropriate if you must, but we docs should make an effort to stay nice to each other-no-one else does! it's already such a demanding job without us all at each other's throats. I've been asked for a medical consult as an SHO to make sure someone is fit for anaesthesia before-by a trainee anaesthetist, out of hours, when the surgery was scheduled for 3pm the next day. I could have gone to town on that, but politely suggested for him to assess the patient first himself and call me if he had any concerns-which he didn't. You catch more flies with honey than you do with vinegar:)

Jane – Thanks for your thoughts. You make some good points about long shifts etc… and surgeons being busy in ED, but – get this – anaesthetists are busy too. Out-of-hours, I have to cover emergency & trauma theatres, A&E calls, Intensive care and HDU, maternity, outreach, the acute pain service and hold the crash bleep too. I work the same hours as doctors in other specialties, so I’m no less tired than they are. I think there’s a general idea that “anaesthetists don’t do much” so we can call them to bail us out - even if it is totally inappropriate to do so (at the time I took this call, I was assessing a 9-year-old girl before taking her to theatre to have her broken arm wired).

Believe me, I know that venflons can be challenging, but at the end of the day, I agree with Ally and think that ALL junior doctors should be able to do them reasonably competently. Don’t get me wrong on this. If something needs doing, it needs doing but, if it is a truly difficult one, then there’s no guarantee that I’ll be able to put one in, or that even if I get it in, it won’t “come out” again and we’ll all be in exactly the same situation a few hours later. The point is, if the patient REALLY needs an IV line, and it is TRULY difficult to get peripheral IV access, then the team should be thinking of getting definitive access – as I suggested.

I’m no bully – what I posted was a shortened version of a longer conversation and I actually come across as being harsher than I actually was - but it does irk me when people try and get me to do their job for them or try to take advantage.

I didn't mean to offend and I know in the UK all docs work similar hours and shifts, didn't mean to imply anaesthetists did anything different. I suppose I just feel that, when I'm called for stuff that to me sounds dumb, I try to look at it as helping someone out rather than doing their job for them. They might do the same for me someday, and I know and remember what it's like being in their shoes. Also, as I pointed out, VERY often it's coming from the registrar, who angrily orders the SHO to get onto anaesthetics NOW, and hence the unwilling SHO gets shot as the messenger-and you can't say to anaesthetics "this is coming from my reg, not me. No they won't try on the patient. " because then anaesthetics will say you said that to the reg-and they'll f***ing kill you. I know-obviously in an ideal world we'd all have a good go or two, get definitive access if that didn't work, and that would be that. Not all registrars are nice people though.Also-every once in a great while there are those people who you just don't quite feel a central line is a good thing for. I know it's woolly-but often in geriatrics for example, we'd treat infections with IV antibiotics for comfort(some didn't in other specialities-but infections can hurt a lot!) and give them IV morphine, and generally be active enough with treatment, but they would not be ICU candidates or for resus. A pneumothorax from a central line would likely finish them off. The procedure itself would be an awful lot for them to handle. At the same time-these frail old things often surprise you and pull through if you just keep at it. But they usually have CRAP CRAP veins! In that context, if no-one can get a line, a central line isn't really appropriate-but neither is withdrawing everything and going for comfort cares only just because they don't have access. PICC lines are a good one-but were very hard to come by in the hospitals I worked in-and in fact-the anaesthetists had to do them too so they would often prefer to do a normal line instead. It's just you guys are so darn talented! and while you're there we can pump you for information on cardiac physiology and pharmacology! as the anaesthetics guys are often the most knowledgeable people in the whole hospital. :)

ouch, you sound pretty angry! I appreciate it must be really annoying getting called about venflons but it does sometimes happen that they need them & nobody can get one in. I had 4 attempts at one last night unsuccessfully, reg & consultant were stuck in theatre and thankfully one of the anaesthetic STs came and had a go for me (took them 3 attempts). When you're shouting down the phone please remember we're not out to annoy you, we know you're busy too. If you want to decline then thats ok but please be polite! It does no-one any good to be yelled at half way through the night.

I really doubt that Shri had called her reg about this patient, and I think if the surgical SHO doesn't even want to speak to their reg about a problem, then I'm even less interested in sorting it out for them. If I had taken this call from the on-call surgical reg, my answer would have been the same - sort it out yourself or get definitive access.

I think what this all boils down to is the question - "Do you think the on-call anaesthetist should come and put venflons into ward patients?" I think the answer is "no." The ward docs should do it, we are needed elsewhere and normally, these patients don't really need a venflon anyway.

I didn't shout at this SHO, but I was firm. I really do think that she was just trying to make me do her job and shift responsibility for sorting out a problem onto my shoulders.

Incidentally, I'm not averse to helping colleagues out. I do this all the time when i'm on call - but only if it's appropriate and the request is reasonable (the scenario that Jane describes is probably reasonable and I'd come and have an attempt). For example, I got a call today from another surgical SHO today (why is always the surgeons?) about a patient who had come for an outpatient CT scan. The surgical SHO couldn't get a venflon in and they asked me to try so the woman could have a proper scan with IV contrast. This is a much more reasonable request and I quickly went down to put the venflon in before going back to ICU to admit a patient (btw the woman had HUGE veins and I really don't get why he couldn't cannulate her - maybe he was just having a bad day). I don't mind helping out but but I do believe that because anaesthetists are "helpful" people try and take advantage of us.

Oh the other thing is that this wasn't at night, it was at about 13:30, so there were plenty of other doctors around on the wards. like I say, I think she was taking the piss.

OH-feck I just assumed it was out of hours-why on EARTH would she call you during the day???I actually agree with you now....there's assloads of people to ask during the day before you drag the anaesthetists out of theatre or soemthing. That is bad form.

I'm a urology reg, and we get similar calls for catheters. It's irritating.

But if there is a venflon that the FY and ST doctors have failed to gain on one of our patients, then i don't think I'm going to be much use. They put in venflons all the time, me extremely rarely. Let alone central lines.

I get called to ITU for catheters. You get called to wards for venous access.

I guess I should learn from other's lesson. HAHA I don't wish to be f***ed up by a registrar.But I think Shri should get things done by herself(is she a chick?). Being too dependent bugs other really much. haha

You are an anaesthetic SHO, and someone asked for some assistance with a difficult line? - i think that is a reasonable request - if you're busy, and access isn't urgent, then fine, politely decline and outline your reasons. But dressing down another junior collegue is a bit bullshit if you ask me. Don't turn into one of those up themselves registrars.

I called an anaesthetist for that very problem when I was a HO. We had a patient who was on a sliding scale minus the venflon and we had problems inserting even 22G cannulas in the gentleman. We got the usual 'I'm not a cannulating service' chat back from the anaesthetist.My reasoning for calling? To ensure that too many people didn't fuck up the veins before the superpro came along.

I guess it depends on the relationship you have with your colleagues and the size of the hospital. Yes, essentially it IS a favour, but I think having worked in a hierarchical hospital enviroment we forget that we are all cogs of one machine that makes up a hospital, trust or the NHS if you will. If you have the time.. why not..

Hey Dr Micheal, I'm a HO and dread speaking to ppl like you. I know anaesthetic SHO's are busy, but we all are!!! You guys are the best people at putting in cannula's in the hospital. I've had patients whom my entire team has spent ages trying to cannulate and the ICU SHO does it in two or three goes. U guys are amazing, like that. Why would I put a patient through so much pain before deciding that it's gonna take a pro to get a line in?

And I know this point has already been made, but some patients are just NOT appropiate candidates for a central line, that doesn't mean they wud'nt benefit from a cannula for IV antobiotics tho'

I think ur blog is brilliant, so opinionated and witty. Please don't turn into one of those unhelpful arsehole registrar's that have totally forgotten how hard it was to be a houseofficer.

I was in the same situation a few weeks ago, during the day with no reg, luckily the ICU reg wasn't you. He cannulated my patient happily.

Anon, Anonymous, StormyThanks for your comments, I think this is a debate that's just going to run on and on.

I'm not averse to helping out with difficult lines - I've done quite a few cannulations recently on the ward when the team couldn't get them. I understand that cannulation can be difficult and believe it or not, I haven't forgotten what it's like to be a house officer (it wasn't that long ago). I am not "up myself" at all - far from it.

I'm pretty approachable and if the request to cannulate sounds reasonable, I'll probably do it if I'm free. What I object to is being seen as the default cannulation service for the hospital. As the post describes, Shri had loads of other doctors around that she could have asked for help, but she would rather pull the anaesthetist out of emergency theatres than to ask another SHO/reg. Do you not see how wholly inappropriate that is?

I recently posted about a typical night shift. Ask yourselves - if you were me, at what point would you have done Shri's venflon? At what point was I less busy than the surg reg on-call that she could have asked?

The fact is that cannulation is a core skill that all doctors should have. If I turn down your request, then you should get uppity or upset or call me "a bit of a cunt," it's a favour you're asking.You should either sort it out yourself or get help from elsewhere. Aren't we all doctors at the end of the day? Isn't sorting out stuff like this what we get paid for?

Btw why is only surgeons that ask? Medical patients are generally older and have tricker veins, yet the medics seem more able to cope. Just an observation

I am coming to the end of my FY1 year and have had an surgical and a medical attachment. The reason why you get the requests from the surgical wards is that the surgical reg asks us to bleep you!!! Ok please dont shoot the messenger!!! Also, do you really think that this shri person was going out of her way to bleep you for a cannula just to piss you off/out of laziness. Honestly, by the time you are bleeping someone for a cannula you are desperate.

I think the appropriate thing to do, rather than chew out the junior doc requesting the venflon, would be to ask them the name and bleep number of their reg who has demanded they bleep you for the "favour". Bleep said registrar and tell them either to a) do their job or b) not be so cowardly as to put their juniors in your firing line but instead to bleep you themselves to ask for the favour if they're so incompetent as not to be able to cannulate one of their own patients. If it keeps happening, pass this irritating reg's number to your most evil consultant and listen while they reduce this self-important tw*t to an appropriate size.

Shocking, asking an anaesthetist to do a cannula? Damn that's like asking a phlebotomist to take blood. They both have other things to do, like anaesthetists to read papers and phlebs to label blood bottles.

Incidentally, putting in a central line when unnecessary calls into question good medical practice doesn't it? The patient being your first concern and all that... Not to mention respect for colleagues, which is clearly lacking here.

Yes, I have other things to do than to do the work of other trained doctors. Things like this and this and this and this and this and this.

Cannulation is a basic skill that medical students, let alone doctors should be able to do. Guess what? after I refused, the patient "magically" got her cannula. The surgeon was just being lazy. That is the point

Cannulation may well be a basic skill, but I can tell you that social etiquette is an even more basic skill. Seeking help when having difficulty is not an issue. Behaving like a twat when someone in difficulty comes to you to seek help is.

Right, I've got to go now and get some consultant anaesthetists to put in cannulas for me. PS, the GMC's (that's the General Medical Council's) Good Medical Practice makes interesting reading.

Difficult situations and difficult resolutions. There are two main issues and to be a rounded person you have to seriously consider them.

Firstly, whether you like it or not there is a reason the call was made and there is a reason those kinds of calls tend to come from surgical specialties. It is not because the HO/SHO wanted to take advantage of you or make you do their job - as easy as it seems, such thinking only reflects an egocentric rationale. The question is unlikely to have had anything to do with you or anaesthetics even, but to do with a breakdown of communication and support in the surgical team. Surgical teams tend to call lots of other specialties. HO/SHO/Registrars only call others for help when they feel unable to solve the problem. If she didn't ask her registrar, this is highly suggestive of the possibility she may have felt unable to. This reflects more of the unapprochable arrogance/idiocy that fools (usually middle-grade and other trainee doctors of all specialities, surgery usually worst hit) develop when they feel their jobs become more important than basic skills of human interaction, than a failing of the junior staff. None of this is about whether or not you can say 'no' to other people or not - you have an entitlement to refuse requests.

It is however never your entitlement to berate people or to subject people to protracted conversation to 'prove a point'. If it's something you don't do, then say you don't do it. If you wish for their registrar to try first then ask them to tell their registrar to call you instead. Your discussion as outlined initially as entertaining as it was, suggested you might have forgotten for a moment however idiotic they may be/sound, you were talking to a human being. If arrogance had absolutely nothing to do with the conversation, then consider this - would you have had the same conversation had a medical director/their consultant asked you to put in the cannula? If not then, why not? Treating people with respect should be irrespective of their designation or your opinion of your social status with respect to theirs.

The second point is similarly important. The question should never have been directed at you in the first place. It is a failing of the institution that such things happen. The only way to deal with such problems is to tackle them at the source. If it infuriates you/annoys you as such, simple speak to their registrars or mention such things at HO/SHO inductions.

Finally, no matter what you do as a doctor, remember it's about the patient not the person on the phone. If you truly can't help them yourself, but are willing to spend the time on the phone, give comprehensive good advice that may help the patient (and maybe the incompetent SHO whose cannulation skills are apparently inadequate).

Dr Michael is just being cocky. The thing to do in such places is to speak to his superior (if he is a reg, then speak to his consultant directly through the switch board). How basic the procedure maybe, anaesthetists pass venflons day in and day out and are definitely better than other specialities (except maybe a few A & E staff). Hence if they are cocky and do not help, all you can do is approach their superiors and if that is not helpful, fil an incident form.

As an Anaesthetic Reg I've fielded plenty of calls for help for canulae. Whenever I'm free, I go and do it. It gives me a good feeling helping out a colleague, who is always grateful, and, most importantly, saves the patient a lot of grief, you know, the whole reason you became a doctor in the first place? Get off your high horse and do the right thing, your comments smack of arrogance.

you surgical guys are pretty much chop it out or stick your finger in itwhy dont you use ultrasoundor sod itGO SURGICAL (ANALAGOUS TO GO POSTAL)STICK IN A STERNAL INTRAOSSEOUS NEEDLE, YOU LOVE THAT DRAMATIC INVASIVE SHITor perhaps investigate why the patient was hypovolaemicif the patient is peripherally shutdown then a peripheral cannulae will be difficult for anyone (and may tissue), hence the central access argument is logical, sounds like such a patient will probably end up in ITU/HDU anyway.Get clever, and use a different argument to get the anaesthetist to assess the patient.The trouble with the UK health service is that it is like dealing with a shit call centre, people are so belligerent.Not everyone is as skilled as you, the intelligent and sensitive doctor is prudent enough to ask the EXPERT for help, of whatever level and speciality.Shame some are people dont respond to CRY FOR HELP, from others genuinely concerned for their patients and wanting expert assistance.If the patient had been the spouse of a consultant, or your own mother would you have gone to cannulate the patient?I believe we should often reflect on our own values and attitudes.Sounding sanctimonius, but anaesthetists ARE expert cannulators due to frequency and experience, thats why they are asked.I would see it as an informal referral to the EXPERT for review as to the appropriate intervention (i.e attempt peripheral or venous cannulation, fluid strategy, admissission to more appropriate treatment centre e,g HDU0, and as such would attend when time and priorities allow.But thats my opinion, however lets get our heads outr fo our own arses and help each other.tiredness of course makes us irritable and arsey, even the best of us!!!!!!!!In ignorance I ask, is Ireland i.e. EIRE following the WTD in practice

i'm reading this thread after having been asked to insert a cannula 3 nights running (not in the same patient), so i'm going to have a little vent here. The requests have all come from nurses, one on a ward and 2 in a&e (yes, A&E FFS. If they can't get a cannula in there's something going amiss, they do more that i do in a day and usually on sicker patients). Now I very rarely refuse to go and help unless i'm really not going to be able to get there, stuck in theatre etc, and i'm just no good at being a twat on the phone, but this really is starting to piss me off. I don't have a go at the nurse - they simply want a cannula in their patient who has been waiting 8 hours for there iv abx, and evidently the vogue at this hospital is for whoever they ask to tell them to call me. i'm only 3 years into anaesthetc training, i can still remember being an F1/2 and there is no way in hell i would have told a nurse to refer my patient to another specialty on my behalf (which is exactly what it is - it's not "a favour", if you need our "specialist skills" it's a referral). I can remember calling the anaethetist a couple of times in a state of high embarrassment as a F2 as our team really couldn't cannulate a patient, and duly setting up a tray of equipment for them and at least hanging around to help or learn from them by watching them use the US. this hospital is fecking rediculous, not a doctor in sight when i turn up - i really don't want an admiring audience but if i ask another specialty to help with a patient on ITU for example, i'll certainly make sure the equipment's available and i'm somewhere in the area to help. And all the cannulas went in first time btw. This is not a demonstration of my immense skill - they really weren't that difficult. Ones that as an F1 i may have needed a couple of goes but wouldn't have been expecting to not get in. So I'm afraid i am now going to be a twat. If i'm feeling generous, a doctor to doctor phone call will do (a bit of professional courtesy i would expect to recieve anyway), and if i'm not, a full written referral will be needed, possibly with reasons as to why they were unable to site the cannula, who else has tried and why calling me was the next appropriate step, rather than for example IR to get it placed by someone who has actually be taught how to use an ultrasound, or perhaps paediatrics/neonates who i can assure you place far more difficult lines than i do on a daily basis.